Daughters say patient safety compromised at Dallas VA Hospital

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by BRETT SHIPP

WFAA

Posted on June 10, 2013 at 10:28 PM

Updated Tuesday, Jun 18 at 5:32 PM

NEWS 8 INVESTIGATES

Patient safety at the Dallas Veterans Affairs Hospital is again being called into question.

Considered to be the agency's worst facility in 2004, the Dallas VA Hospital has received more than 30 certification agency complaints in the last three years.

And now, there are two more.

Two daughters agreed to discuss the deaths of their fathers and the conditions they say no veteran should have to endure.

The Veterans Affairs is the largest health care system in the nation, serving more than eight million veterans a year. VA officials in Washington D.C. pledge “to never compromise the safety, security or well-being of veterans."

Sydney Schoellman says the government has shattered that pledge.

Her father, Korean War veteran Gary Willingham, trusted his care to doctors at the Dallas VA hospital. In November 2010, Willingham went to the VA for what his daughter believed would be a short operation to remove a tumor from his neck.

But six hours after surgery began, Schoellman said two doctors finally emerged. "They never really admitted that anything went terribly wrong,” she said. "They kind of just padded around that."

Schoellman said what they did tell her is that her father had lost a lot of blood, and that they had accidentally clamped off his carotid artery for six minutes.

When she and her family were allowed to see Willingham, she said she was in shock.

"What we saw wasn't the man we grew up with," Schoellman said. "That wasn't the man that we'd seen how many hours earlier."

With his carotid artery clamped and his brain starved of oxygen, Willingham had, in effect, suffered a debilitating stroke.

Schoellman's once-energetic father was now bedridden and would spend the next year before he died unable to eat or drink on his own.

Outraged, Schoellman started to dig, asking for the detailed surgical notes from the day of the operation.

"I was informed by one of the employees at the Dallas VA that I should get those records before they disappeared," she said.

Deep in the surgical notes Schoellman said she found a disturbing revelation: The carotid artery had been clamped not for six minutes — as she said she was told — but for 15 minutes.

"If we had known it was 15 minutes, we wouldn't have allowed the things that went on. We would have let him end his life with dignity and the grace he lived it with before the surgery," Schoellman said.

Willingham's family has since filed a formal complaint and a legal claim against the Dallas VA for improper care.

Tammie Wilson has also filed a complaint with the Dallas VA, saying her father — decorated Vietnam vet Gary McGrew — was stripped of his dignity as well.

Admitted to the Dallas VA this past February with two broken arms, Wilson said her father agonized for hours without pain medicine.

"They just dawdled and dawdled, and it might have been six hours in-between," Wilson said. "I would just keep going out to the nurses' station saying, "Please, please!' They would respond slowly, if at all."

Wilson said no one seemed to be aware that her father was in his final stages in a fight with cancer. She said nurses were still trying to feed him in the minutes he was taking his last breaths.

"Here comes this nurse, stirring up the same pills and the same apple sauce he had spit out the night before because he couldn't even take a drink of water," Wilson said.

Administrators at the Dallas VA have declined to discuss either of the complaints with News 8, saying they either can't due to pending legal action or to lack of proper authorization. Days later, Director Jeffrey Milligan released a full statement, which you can read here.

They also say the complaints filed against them with the Joint Commission, the hospital accreditation agency, have been investigated and closed. They said the VA "maintains a safe and sanitary environment" and "invite families to discuss their concerns and complaints ... through several means available to them."

Schoellman said the only means left for her family is the courts, along with her ability to speak out for the veterans who cannot.

"These are some of the greatest national treasures that we have, and they walk in every day, and these families are blindsided by the pain and the agony of losing someone at the hands of people who are never held accountable," Schoellman said.

Last fall, News 8 investigated complaints about quality of care at the Dallas VA. The Inspector General with the Veterans Affairs last fall also found excessive wait times and irregularities with referrals and appointments.

Rep. Eddie Bernice Johnson (D-Dallas) said her office has also received complaints.

"While I am unable to comment directly on any information I have received from my constituents, many of these complaints pertain directly to the quality and timeliness of patient care," Johnson said. "The VA’s own Inspector General reports — which are public record — bear out the delays and shortcomings in patient care."

“I have repeatedly expressed my concerns to the VA in Dallas and in Washington D.C., in direct response to those complaints," the congresswoman added. "The single most important responsibility of the VA is to meet the health challenges that our veterans face. While I have worked directly with [VA] Secretary [Eric] Shinseki's office on numerous occasions within the past year, the VA at the local and federal levels have not responded impartially to these complaints. It has always been my hope that the leadership at the VA would have taken their own initiative to address these issues. I will do everything necessary to address the concerns of my constituents and patients of the VA North Texas Healthcare System. So long as the VA’s ability to meet those challenges remains in question, I will not rest until these issues are resolved.”

Below is a statement issued on June 18 from Director Jeffrey Milligan: 

Regarding the ongoing investigation of patient care at Dallas VA Medical Center, understand that we are not allowed to reveal the health care treatment of patients when the patient/family has not executed signed consent or when there are pending legal proceedings. As such, when we are not allowed to speak publicly, fair and balanced reporting suffers. Regardless, protecting patient privacy is the law and VA North Texas Health Care System (VANTHCS) will not compromise patient privacy.

Although we have not been able to discuss the cases in your stories, in the future and in the interest of providing both truth and fairness to your viewers, you should be aware that we are a recognized national leader in health care safety and quality by focusing on continuous quality improvement.

WFAA replays “Dallas VA Medical Center was the worst VA in the Nation in 2004.” VANTHCS is not the same organization it was nine years ago.  VANTHCS meets or exceeds 92 percent of the goals given to us nationally that measure quality of care, preventive care, and access to care. VANTHCS is a high performing organization.

Here are some important facts that should be included in providing balance and truth in your reporting: 

  • Recognized by the VA National Center for Patient Safety; VANTHCS won the bronze Cornerstone Award in 2008 and gold in 2009, 2010 and 2012 for outstanding achievement in identifying, analyzing and resolving patient safety issues. 
  • VHA Systems Redesign Champion - 1st Place Award in 2010 for significant improvements in patient throughput.
  • Recognized by VA’s Green Building Initiative for achievements in sustainable energy and reducing environmental impact.
  • Awarded the 2010 Robert W. Carey Excellence Award from the Secretary of Veterans Affairs.
  • 2010 VA Engineering Green Building Initiative  (green globe) award

A caring staff is our best resource, and most have the best interest for Veterans and their families at heart. It is unfortunate when dedicated employees become discouraged because some media show no interest in all the great things accomplished here every day.

When my office received queries from your reporters, we respond transparently and as the law allows. I hope you will consider ending this unfair, unbalanced reporting. 

Sincerely,

Jeffery Milligan

 

Director, VA North Texas Health Care System

E-mail bshipp@wfaa.com

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